Exoskeleton-assisted Gait Training in Persons With Multiple Sclerosis: A Single-Group Pilot Study

Published:December 07, 2019DOI:



      To investigate the feasibility of conducting exoskeleton-assisted gait training (EGT) and the effects of EGT on gait, metabolic expenditure, and physical function in persons with multiple sclerosis (MS).


      Single-group pilot study.


      Research laboratory in a rehabilitation hospital.


      Individuals with MS (N=10; mean age, 54.3±12.4y) and Expanded Disability Status Scale 6.0-7.5.


      All participants completed up to 15 sessions of EGT.

      Main Outcome Measures

      Timed 25-foot walk test at self-selected and fast speed, 6-minute walk test, metabolic expenditure of walking and timed Up and Go test were assessed during walking without the exoskeleton at baseline and immediate post training.


      All participants tolerated the training intensity and completed training without adverse events. After training, gait speed was improved and metabolic expenditure was reduced significantly during the timed 25-foot walk test at self-selected speed.


      EGT is not only feasible but may also improve gait efficiency for persons with MS. Our observed improvement in gait speed was associated with reduced metabolic expenditure, which was likely because of improved neuromotor coordination. Further studies are required to investigate the effectiveness and integration of EGT in the continuum of MS rehabilitation.


      List of abbreviations:

      BWSTT (body weight–supported treadmill training), EDSS (Expanded Disability Status Scale), EGT (exoskeleton-assisted gait training), FS (fast speed), MS (multiple sclerosis), NVO2peak (normalized peak oxygen consumption), RAGT (robotic-assisted gait training), T25FW (timed 25-foot Walk), TUG (timed Up and Go), SS (self-selected speed), 6MWT (6-minute walk test), VO2peak (peak oxygen consumption)
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        • Ortiz G.G.
        • Pacheco-Moisés F.P.
        • Bitzer-Quintero O.K.
        • et al.
        Immunology and oxidative stress in multiple sclerosis: clinical and basic approach.
        Clin Dev Immunol. 2013; 2013: 708659
        • Cavanaugh J.T.
        • Gappmaier V.O.
        • Dibble L.E.
        • et al.
        Ambulatory activity in individuals with multiple sclerosis.
        J Neurol Phys Ther. 2011; 35: 26-33
        • Feinstein A.
        • Freeman J.
        • Lo A.C.
        Treatment of progressive multiple sclerosis: what works, what does not, and what is needed.
        Lancet Neurol. 2015; 14: 194-207
        • Waters R.L.
        • Mulroy S.
        The energy expenditure of normal and pathologic gait.
        Gait Posture. 1999; 9: 207-231
        • Heesen C.
        • Böhm J.
        • Reich C.
        • et al.
        Patient perception of bodily functions in multiple sclerosis: gait and visual function are the most valuable.
        Mult Scler. 2008; 14: 988-991
        • Vaney C.
        • Gattlen B.
        • Lugon-Moulin V.
        • et al.
        Robotic-assisted step training (lokomat) not superior to equal intensity of over-ground rehabilitation in patients with multiple sclerosis.
        Neurorehabil Neural Repair. 2012; 26: 212-221
        • Schwartz I.
        • Sajin A.
        • Moreh E.
        • et al.
        Robot-assisted gait training in multiple sclerosis patients: a randomized trial.
        Mult Scler. 2012; 18: 881-890
        • Beer S.
        • Aschbacher B.
        • Manoglou D.
        • et al.
        Robot-assisted gait training in multiple sclerosis: a pilot randomized trial.
        Mult Scler. 2008; 14: 231-236
        • Pilutti L.A.
        • Lelli D.A.
        • Paulseth J.E.
        • et al.
        Effects of 12 weeks of supported treadmill training on functional ability and quality of life in progressive multiple sclerosis: a pilot study.
        Arch Phys Med Rehabil. 2011; 92: 31-36
        • Lo A.C.
        • Triche E.W.
        Improving gait in multiple sclerosis using robot-assisted, body weight supported treadmill training.
        Neurorehabil Neural Repair. 2008; 22: 661-671
        • Puh U.
        • Baer G.D.
        A comparison of treadmill walking and overground walking in independently ambulant stroke patients: a pilot study.
        Disabil Rehabil. 2009; 31: 202-210
        • Alton F.
        • Baldey L.
        • Caplan S.
        • et al.
        A kinematic comparison of overground and treadmill walking.
        Clin Biomech (Bristol, Avon). 1998; 13: 434-440
        • Zeilig G.
        • Weingarden H.
        • Zwecker M.
        • et al.
        Safety and tolerance of the ReWalk exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study.
        J Spinal Cord Med. 2012; 35: 96-101
        • Kolakowsky-Hayner S.A.
        • Crew J.
        • Moran S.
        • et al.
        Safety and feasibility of using the EksoTM bionic exoskeleton to aid ambulation after spinal cord injury.
        J Spine. 2013; 4
        • Esquenazi A.
        • Talaty M.
        • Packel A.
        • et al.
        The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury.
        Am J Phys Med Rehabil. 2012; 91: 911-921
        • Aach M.
        • Cruciger O.
        • Sczesny-Kaiser M.
        • et al.
        Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study.
        Spine J. 2014; 14: 2847-2853
        • Kozlowski A.J.
        • Fabian M.
        • Lad D.
        • et al.
        Feasibility and safety of a powered exoskeleton for assisted walking for persons with multiple sclerosis: a single-group preliminary study.
        Arch Phys Med Rehabil. 2017; 98: 1300-1307
        • McGibbon C.A.
        • Sexton A.
        • Jayaraman A.
        • et al.
        Evaluation of the Keeogo exoskeleton for assisting ambulatory activities in people with multiple sclerosis: an open-label, randomized, cross-over trial.
        J Neuroeng Rehabil. 2018; 15: 117
        • Kurtzke J.F.
        Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
        Neurology. 1983; 33: 1444-1452
        • Smith M.T.
        • Baer G.D.
        Achievement of simple mobility milestones after stroke.
        Arch Phys Med Rehabil. 1999; 80: 442-447
        • Duffield R.
        • Dawson B.
        • Pinnington H.
        • et al.
        Accuracy and reliability of a Cosmed K4b2 portable gas analysis system.
        J Sci Med Sport. 2004; 7: 11-22
        • Bohannon R.W.
        • Glenney S.S.
        Minimal clinically important difference for change in comfortable gait speed of adults with pathology: a systematic review.
        J Eval Clin Pract. 2014; 20: 295-300
        • Buesing C.
        • Fisch G.
        • O'Donnell M.
        • et al.
        Effects of a wearable exoskeleton stride management assist system (SMA(R)) on spatiotemporal gait characteristics in individuals after stroke: a randomized controlled trial.
        J Neuroeng Rehabil. 2015; 12: 69
        • Chang S.H.
        • Afzal T.
        • TIRR SCI Exoskeleton Group
        • Berliner J.
        • Francisco G.E.
        Exoskeleton-assisted gait training to improve gait in individuals with spinal cord injury: a pilot randomized study.
        Pilot Feasibility Stud. 2018; 4: 62
        • Hubbard I.J.
        • Parsons M.W.
        • Neilson C.
        • et al.
        Task-specific training: evidence for and translation to clinical practice.
        Occup Ther Int. 2009; 16: 175-189
        • Page S.J.
        Intensity versus task-specificity after stroke: how important is intensity?.
        Am J Phys Med Rehabil. 2003; 82: 730-732
        • Hornby T.G.
        • Holleran C.L.
        • Hennessy P.W.
        • et al.
        Variable Intensive Early Walking Poststroke (VIEWS): a randomized controlled trial.
        Neurorehabil Neural Repair. 2016; 30: 440-450
        • Newman M.
        • Dawes H.
        • Van den Berg M.
        • et al.
        Can aerobic treadmill training reduce the effort of walking and fatigue in people with multiple sclerosis: a pilot study.
        Mult Scler. 2007; 13: 113-119
        • Eng J.J.
        • Tang P.F.
        Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence.
        Expert Rev Neurother. 2007; 7: 1417-1436
        • Sebastiao E.
        • Bollaert R.E.
        • Hubbard E.A.
        • et al.
        Gait variability and energy cost of over-ground walking in persons with multiple sclerosis: a cross-sectional study.
        Am J Phys Med Rehabil. 2018; 97: 646-650